Citations

Objectives On rare occasions, hiccups can cause morbidity, such as sleep deprivation, aspiration and even death. At times, palliative invasive procedures are considered. This study tested the hypothesis that invasive procedures can provide hiccup palliation with an acceptable safety profile. Methods Multi-site electronic medical data were used to assess adult patients who underwent an invasive procedure for hiccups between January 1995 and January 2022. Hiccup palliation was defined as documented improvement in severity or frequency of this sign/symptom after the procedure. Results A total of 69 patients underwent one or more invasive procedures for hiccups (144 total procedures). Fifty-nine patients (86%) were men. The most frequent initial procedure was a phrenic nerve block (n=10) followed by oesophageal dilation (n=9). Only 31 patients (45%) manifested hiccup palliation after their first procedure. Nearly half, or 32 patients (46%), underwent more than one procedure (2 underwent nine procedures). Of these subsequent procedures, 35 resulted in palliation. Five adverse events arose from 144 procedures: post-esophagectomy atrial fibrillation, haematoma after cardiac device removal, vocal cord immobility after craniotomy, vocal cord immobility after vagal nerve manipulation, and a cerebral spinal leak after vagal nerve decompression. Conclusions Invasive procedures can palliate hiccups with an acceptable safety profile. However, these procedures appear to palliate hiccups in only about half of patients and sometimes do so only transiently.

Introduction Lactating physicians face considerable challenges in achieving lactation goals due to inflexible schedules and a lack of break time. While federal mandates have outlined the necessity of lactation breaks, the frequency and duration of breaks are unspecified. The objective of this study was to fill this gap by designing and implementing an outpatient neurology resident clinic schedule with protected lactation breaks, ensuring support and quality of trainees’ educational experience. Methods This quality improvement study began with developing a prototype schedule with input from lactating physicians, a lactation consultant, and neurology residency program leadership. Neurology residents and fellows with prior lactation experience were surveyed to determine if the proposed schedule would have fit their individual needs. The clinic schedule with protected lactation break time was then implemented, and lactating neurology residents were surveyed regarding their experience. Results Eleven previously lactating neurology residents and fellows who were surveyed about the proposed schedule agreed that the prototype schedule would suffice for their personal lactation needs. The clinic schedule was implemented for 5 neurology residents returning from maternity leave in 2022 to 2023, and 4 residents completed a survey of their experience. There was unanimous agreement that protected lactation breaks helped residents achieve their lactation goals and strongly benefited work/life balance and overall well-being. Despite this intervention, 75% of respondents stopped breastfeeding earlier than intended, and 100% of respondents experienced complications perceived to be related to inadequate pumping, such as diminished milk supply. Ongoing barriers to achieving breastfeeding goals included work interrupting lactation breaks, lack of lactation rooms, and lack of computer workstations in lactation rooms. Conclusions Inclusion of protected lactation breaks in outpatient clinic schedules helped neurology residents achieve their lactation goals as well as promoted work/life balance and overall well-being. However, more work is needed to address other barriers to achieving lactation goals.

Background Many guidelines list migraine with aura (MwA) as a contraindication to estrogen-containing combined hormonal contraceptives (CHCs) due to vascular risks. However, current evidence is based on small sample studies with potential influence by confounding factors. Additionally, few studies have examined the vascular risk associated with modern CHCs with lower dose estrogen, particularly in relation to aura status. The present study aims to investigate the vascular risk of modern CHCs in women with migraine with and without aura. Methods We used a de-identified electronic medical record database with 120 million patients across multiple health systems in the United States of America. We included female patients aged 18–45 years who received a migraine diagnosis code, had at least three office visits within three years, and were prescribed at least one migraine-specific medication within 6 months following the first outpatient visit. All data after 2010 were included. Patients with prior cardiovascular events were excluded. Our composite endpoint consisted of acute ischemic stroke, acute myocardial infarction, deep vein thrombosis/pulmonary embolism and intravenous thrombolytic administration. We stratified our analysis according to CHC exposure and aura status and compared the incidence of the endpoint with high-dimensional propensity score-matching between CHC users and non-users in (i) the overall cohort, (ii) MwA and (iii) migraine without aura (MwoA); between MwA and MwoA in (iv) patients prescribed CHCs; and in (v) those without CHC prescriptions. Results We included 5535 patients who received CHC prescriptions and 21,520 who did not. 114 (2.06%) of CHC users and 547 (2.54%) of CHC non-users had at least one vascular event. With propensity score-matched comparison, the composite endpoint did not significantly differ between CHC and non-CHC in the overall migraine group, those with MwA and the MwoA group. In those prescribed CHC, MwA and MwoA did not differ in all the outcomes. For CHC non-users, MwA was associated with a higher incidence of acute ischemic stroke (hazard ratio = 2.45; 95% confidence interval = 1.58–3.78; p < 0.001; n = 6201 in each group) and the composite endpoint (hazard ratio = 1.34; 95% confidence interval = 1.08–1.67; p = 0.008). Conclusions Our real-world study showed that exposure to modern CHC was not associated with a significant increase in vascular risk in women aged 18–45 years with migraine, MwA or MwoA who have no prior cardiovascular events. However, in those who never received CHC, MwA was associated with higher vascular risks compared to MwoA. While limitations exist using large scale electronic medical record databases for analysis, our results suggest that carefully designed prospective studies should be conducted to reassess the vascular risk associated with CHC use in women with migraine, especially MwA.

Autoantibodies contribute to many autoimmune diseases, yet there is no approved therapy to neutralize them selectively. A popular mouse model, experimental autoimmune encephalomyelitis (EAE), could serve to develop such a therapy, provided we can better understand the nature and importance of the autoantibodies involved. Here, we report the finding of autoantibody-secreting extrafollicular plasmablasts in EAE induced with specific myelin oligodendrocyte glycoprotein (MOG) antigens. Single-cell RNA sequencing reveals that these cells produce nonaffinity-matured IgG antibodies. These include pathogenic antibodies competing for shared binding space on MOG’s extracellular domain. Interestingly, the synthetic anti-MOG antibody 8-18C5 can prevent the binding of pathogenic antibodies from either EAE mice or people with MOG antibody disease. Moreover, an 8-18C5 variant carrying the NNAS mutation, which inactivates its effector functions, can reduce EAE severity and promote functional recovery. In brief, this study provides not only a comprehensive characterization of the humoral response in EAE models but also a proof of concept for a therapy to antagonize pathogenic anti-MOG antibodies.

Hemodynamic progression of valvular aortic stenosis was studied in 54 patients who had serial cardiac catheterizations. There were 47 men and 7 women with a mean age of 61.2 years. The time interval between studies was 4.4 years (range, 0.4‐12.2). Associated coronary artery disease was present in 37 patients (69%). The initial mean aortic valve area (Hakki's formula) was 1.26 cm 2 (range, 0.66‐2.85), and the aortic valve area at last follow‐up was 0.77 cm 2 (range, 0.29‐1.95), with mean reduction of 0.49 cm 2 . The mean peak systolic gradient increased from 23.3 ± 15.1 mm Hg at initial study to 52.6 ± 27.5 mm Hg at last study, a mean increase of 29.3 ± 23.6 mm Hg. Patients with no or mild left ventricular impairment and no or mild coronary artery disease are more likely to have progression than patients with more severe left ventricular impairment or coronary artery disease (P < 0.05). Aortic valve replacement for progressive aortic stenosis was required at a later date after coronary artery bypass grafting in a small group of nine patients. In this small group, there was a high intraoperative mortality of 33%.

Physician burnout is prevalent and contributes to the high number of physicians choosing to leave clinical practice. The field of hematology-oncology (HO) poses unique challenges for trainees and staff physicians who have to deliver bad news, manage complicated psychosocial situations, deal with the limited ability to prolong life, and juggle multiple time-sensitive demands from coworkers, patients, and families. Furthermore, they often face the death of their patients, along with its emotional toll on patients’ families and the physicians themselves. Burnout in HO is prevalent and increasing, with many physicians reporting in several studies that they plan to reduce working hours and/or retire early. The demand for hematologists and oncologists is rapidly rising, but in the setting of a worsening HO workforce shortage and an increasing number of patients with cancer. Therefore, it is imperative to develop strategies to mitigate or address burnout in HO physicians to improve well-being and prevent attrition. Herein, we describe risk factors and causes of physician burnout in HO trainees and practicing physicians in the United States, with a focus on institutional and individual strategies to address this issue. We also provide recommendations to address the burnout epidemic from the HO standpoint.

Importance Little is known about food insecurity (FI) among graduate medical education (GME) trainees or how FI might relate to well-being outcomes in this population. Objectives To assess the prevalence of and factors associated with FI among GME trainees and to investigate the associations of FI with well-being outcomes such as burnout and social isolation in this population. Design, Setting, and Participants In this cross-sectional study, a survey was distributed among 3408 resident and fellow physicians at 4 geographically distinct sites within 2 US academic institutions from May 2 to June 21, 2023. All resident and fellow physicians appointed at both institutions were eligible and were invited by email to participate. Main Outcomes and Measures The primary outcome was prevalence of FI. Measurement instruments included a 2-item FI screening tool, a 2-item measure of burnout, items addressing intent to stay at one’s institution, social isolation, and demographic characteristics. Univariable analysis and multivariable Poisson and linear regression were used to characterize prevalence and factors associated with FI and associations with well-being outcomes and intent to stay at the institution. Results Of those eligible, 1656 residents and fellows participated in the survey (a response rate of 48.6%). Of these respondents, 735 of 1458 (50.4%) who indicated their gender identified as men and 365 of 1402 (26.0%) who indicated their parental status reported having children. Of the 1551 respondents who reported their age, 519 (33.5%) were younger than 30 years, 770 (49.6%) were aged 31 to 35 years, 169 (10.9%) were aged 36 to 40 years, and 53 (3.4%) were older than 40 years. Among 1457 respondents indicating their race and ethnicity, the majority were Asian (310 [21.3%]) or White (654 [44.9%]). The overall prevalence of FI was 13.7%. FI proportions differed across training sites, with higher levels in large metropolitan locations (15.6%, 17.0%, and 21.3% for the 3 sites in large metropolitan areas vs 4.5% for the site in a small metropolitan area; P &amp;lt; .001). There were also differences by postgraduate year (16.9% for postgraduate year 1 vs 10.1% for postgraduate year ≥5; P = .003) and race and ethnicity (22.4% for Black or African American trainees compared with 8.4% for White trainees; P = .04). Those with FI were more likely to experience burnout (adjusted relative risk, 1.37 [95% CI, 1.18-1.60]; P &amp;lt; .001), were less likely to consider remaining at their institution after training (adjusted relative risk, 0.81 [95% CI, 0.68-0.98]; P = .02), and had higher social isolation scores (T-score parameter estimate 2.37 [95% CI, 0.89-3.86]; P = .002). Conclusions and Relevance In this cross-sectional study, nearly 1 in 7 GME trainees screened positive for FI. FI was associated with important well-being outcomes including burnout. These findings suggest that academic medical institutions should pursue systemic solutions to address FI among resident and fellow physicians as a means of supporting their well-being.

Importance Primary mitral regurgitation (MR) is a prevalent valvular lesion. Current American College of Cardiology/American Heart Association guidelines include class I recommendations for intervention for severe primary MR at the onset of symptoms, significant left ventricular (LV) enlargement (end-systolic dimension ≥40 mm), or dysfunction (ejection fraction ≤60%), with a class IIA recommendation for mitral valve repair when performed at an experienced surgical center. Recent data suggest a survival penalty when waiting for class I surgical guideline indications, and novel markers of decompensation are under investigation. Observations Comprehensive assessment of MR severity using echocardiography is critical, and when warranted, cardiac magnetic resonance (CMR) is complementary. Assessment of LV size and function, as well as serial changes in both, is crucial for determining timing of surgery. New-onset atrial fibrillation, left atrial enlargement, pulmonary hypertension, and exercise-induced changes in LV function should also be considered in borderline scenarios. The roles of LV volumes, global longitudinal strain, CMR-derived measures of myocardial dysfunction, and cardiac biomarkers are worthy of further investigation regarding consideration for early surgical intervention. Conclusions and Relevance A more refined approach incorporating assessment of extravalvular cardiac injury, novel imaging markers, and biomarkers is needed to optimize surgical timing in primary MR. Further research is warranted to validate these emerging parameters and refine guidelines to improve patient outcomes.

Abstract Combination therapy incorporating programmed cell death protein 1 (PD-1) blockade results in unprecedented response rates in both frontline and relapsed/refractory (R/R) classical Hodgkin lymphoma (cHL). Previous retrospective studies have suggested benefit for PD-1 blockade before autologous stem cell transplant (ASCT) but included few patients receiving PD-1 blockade with cytotoxic chemotherapy. To explore the impact of anti–PD-1 based salvage on outcomes for patients with R/R cHL, we retrospectively reviewed 1280 patients with R/R cHL who underwent ASCT from 2010 to 2022 at 6 transplant centers, none of whom received PD-1 blockade as part of frontline therapy. Overall, 25% received a PD-1 inhibitor at any point before ASCT (10% in conjunction with chemotherapy), 28% received salvage brentuximab vedotin (BV) without PD-1 blockade, and the rest received salvage chemotherapy alone. Patients who received PD-1 inhibitors at any point before ASCT had a significantly higher 2-year progression-free survival than those who received BV without PD-1 inhibitors or patients receiving chemotherapy alone (88.2%, 70.2%, and 67.4%, respectively; P&lt; .0001). When restricted to patients in complete response before ASCT, the benefit of PD-1 blockade remained significant. PD-1 blockade before ASCT is independently associated with superior post-ASCT outcomes and patients proceeding to ASCT should be treated with PD-1–based salvage.